Racial/Ethnic Data Collection Form

Racial/Ethnic Data Collection Form

Child and Adult Care Food Program

Per FNS Instruction 113-1: Civil Rights Compliance and Enforcement, each institution is required to establish a system for obtaining actual data by race and ethnic category of program participants for each facility.

This data must be collected each year, maintained on file at the institution, and retained for three years. The data must be safeguarded and access restricted to authorized personnel only.

Institutions may use the Income Eligibility Statement (IES), section 4, to gather this information. However, if there is no IES on file, or the household did not complete this section, the institution may use visual identification to determine the participant’s racial or ethnic group, or the parent or household member may be asked to identify the racial or ethnic group of the participant.

DO NOT SUBMIT THIS FORM TO BRIGHT FROM THE START UNLESS REQUESTED TO DO SO.

Facility Name & Address: / Date Data Collected:
Name and Title of Person completing form: / Total Enrollment:
Instructions for completion:
1)In Section I, input the number of participants enrolled in the facility based on the two ethnic categories: a) Of Hispanic or Latino origin; or b) Not of Hispanic or Latino origin.
2)In Section II, input the number of participants enrolled in the facility by racial category based on the five categories listed.
The total number of participants by ethnic category (Section I, Item C) and the total number by racial category (Section II, Item F) must equal.

Section I: Ethnic Category

/

Number of Participants

A) Hispanic or Latino (A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race. The term “Spanish origin” can be used in addition to “Hispanic or Latino)
B) Not Hispanic or Latino

C) TOTAL NUMBER OF PARTICIPANTS BY ETHNIC CATEGORY

Section II: Racial Category

/

Number of Participants

A) Alaskan Native or Native American (A person having origins in any of the original peoples on North America, and who maintains cultural identification through tribal affiliation or community recognition [includes Aleuts and Eskimos]).
B) Asian (A person having origins in any of the original peoples of the Far East, Southeast Asia, the Indian subcontinent, or the Pacific Islands, for example Cambodia, China, India, Japan, Korea, the Philippine Islands, Thailand, Malaysia, Pakistan and Vietnam).
C) Black or African American(A person having origins in the black racial groups of Africa).
D) Native Hawaiian or other Pacific Islander (A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands).
E) White (A person having origins in any of the original peoples of Europe, North Africa, or the Middle East).

F) TOTAL NUMBER OF PARTICIPANTS BY RACIAL CATEGORY

I certify to the best of my knowledge and belief that the above information is collected in accordance with USDA guidelines and is accurate and complete. This data will be kept on file for a minimum of 3 years.
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Signature Date

Revised 9/07